The nurse has received SBAR report for their four assigned patients on a cardiac unit. Which patient will the nurse prioritize to assess first?
The patient newly diagnosed with heart failure whose pulse oximetry is 94% on 2L oxygen.
A patient scheduled for echocardiogram who has altered level of consciousness and restlessness.
The patient who has dyspnea on exertion but wants to be discharged against medical advice.
The patient whose ejection fraction (EF) is 50% and has 2+ bilateral lower extremity edema.
The Correct Answer is B
Choice A reason: The patient with heart failure whose pulse oximetry is 94% on 2L oxygen is stable at the moment. While they require monitoring, they do not take immediate priority over the patient with altered consciousness.
Choice B reason: Altered level of consciousness and restlessness are critical symptoms that require immediate assessment. These could indicate a life-threatening condition such as hypoxia, electrolyte imbalance, or stroke, necessitating prompt evaluation and intervention.
Choice C reason: The patient with dyspnea on exertion who wants to be discharged against medical advice is important, but altered consciousness takes precedence due to its potential severity.
Choice D reason: The patient with an ejection fraction of 50% and 2+ bilateral lower extremity edema is stable and does not require immediate intervention compared to the patient with altered consciousness.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: While acute pain is a possibility in peripheral neuropathy, infection poses a more serious risk. The sensory deficits in peripheral neuropathy can lead to unnoticed injuries and subsequent infections, especially in the lower extremities.
Choice B reason: Infection is a major risk in patients with peripheral neuropathy due to the loss of sensation, which can result in unnoticed injuries that can become infected. Additionally, high blood sugar levels in diabetes can impair the immune response, making infections more likely and harder to heal.
Correct Answer is K
Explanation
Choice A reason: Atenolol 25 mg oral tablet with breakfast is a common beta-blocker used to manage heart conditions, but it does not indicate an immediate priority.
Choice B reason: Captopril 25 mg three times a day is an ACE inhibitor used to manage blood pressure and heart failure but is not an immediate priority unless there are contraindications.
Choice C reason: Hydrochlorothiazide 25 mg twice a day is a diuretic used to manage fluid retention and blood pressure. While important, it is not the immediate priority unless there are contraindications.
Choice D reason: Aspirin 81 mg tablet every day is a common medication for preventing blood clots but is not an immediate priority unless there are contraindications or interactions.
Choice E reason: Digoxin 0.125 mg every other day is used to manage heart conditions but is not the immediate priority unless there are contraindications or interactions.
Choice F reason: Furosemide 20 mg at bedtime is a diuretic used to manage fluid retention and blood pressure. While important, it is not the immediate priority unless there are contraindications.
Choice G reason: Multivitamin one tablet daily is a common supplement and is not the immediate priority.
Choice H reason: Some doses of medication are missing, which needs to be addressed, but it is not the immediate priority.
Choice I reason: Some routes of medications are missing, which needs to be addressed, but it is not the immediate priority.
Choice J reason: Some medications are duplicated, which is important but not the immediate priority unless it poses a risk to the patient.
Choice K reason: The medications have drug-drug interactions is the priority for the nurse to address. Drug-drug interactions can lead to adverse effects and complications, especially in a patient with multiple conditions such as heart failure, asthma, and kidney disease. Ensuring that medications are safe and do not interact negatively is crucial for patient safety.
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